DESCRIPTION (adapted from the application) Orthotopic liver transplantation is the treatment of choice for selected patients with end-stage liver disease (ESLD). Unfortunately, liver allografts are a scarce resource. The disparity between the supply and demand for donor livers creates a potential for bias in the selection of organ recipients and the allocation of available organs. There is evidence that liver transplants are less available to blacks that to whites, despite a higher burden of ESLD, and higher rates of death from ESLD among blacks. Several small studies have suggested that barriers do exist for black patients with ESLD, but these barriers have not been defined. The overall goal of this grant is to determine what and where the barriers to transplantation are for black patients with ESLD. We will examine two components of the pre-transplant process in this study. We will focus on the referral process from the physician to the transplant center, and on patient perceptions of liver transplantation and the transplantation process. The specific aims of our study are: 1) To compare the referral rates for liver transplant evaluation and the overall clinical outcome in black and white patients with ESLD who were treated at three urban hospitals in Boston between 1994 and 1998, and 2) To determine if there are racial differences in knowledge and preferences about liver transplantation among patients with chronic liver disease. We will perform a retrospective cohort study of black and white patients with ESLD to determine if there are different rates of referral for liver transplant based on race. We will examine the clinical, financial, social, socioeconomic, and demographic factors that influence the rates of referral for liver transplant evaluation for these populations. We will also test the hypothesis that patient knowledge, attitudes and preferences about liver transplantation vary according to race and may influence the willingness of patients with ESLD to accept a liver transplant. To accomplish this, we will conduct a survey of a racially diverse group of patients with chronic liver disease. We will develop an appropriate instrument during the course of this grant, validate and pre-test it, then administer it to our study cohort. Advanced-level coursework in clinical epidemiology, biostatistics, survey development, and outcomes will also be a critical element of this project.